Budnitz and colleagues (1) recently reported on emergency department visits attributed to adverse drug reactions in the elderly. Although the authors identified medications that represent an important safety risk to the elderly, we disagree with their conclusion that the “Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events.” Their method of identifying attribution of risk may be severely flawed for several reasons.

The authors required that the emergency department physician explicitly attribute the diagnosis to use of medication. Most emergency department physicians would not miss the fact that hypoglycemia or hyperglycemia was related to insulin use or the fact that bleeding with an elevated international normalized ratio was related to warfarin use. Elevated digoxin levels are easily measured as well. However, these physicians would probably be far less likely to recognize that an antihistamine contributed to a fall-related injury, delirium, or urinary retention. Indeed, they might not even have known that the patient was using the drug. Without a chart review, the investigators may have significantly underestimated the contribution of drugs listed in the Beers criteria. We are surprised that this limitation was not even discussed.